Provider Demographics
NPI:1609224203
Name:MENTOR ABI, LLC
Entity Type:Organization
Organization Name:MENTOR ABI, LLC
Other - Org Name:NEURORESTORATIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-321-5706
Mailing Address - Street 1:306 W MILL ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2727
Mailing Address - Country:US
Mailing Address - Phone:618-529-3060
Mailing Address - Fax:
Practice Address - Street 1:6006 BEVERLY RD SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-7114
Practice Address - Country:US
Practice Address - Phone:540-577-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital